title: Outcome of antegrade continent enema (ACE) procedures in children and young adults.
abstract: OBJECTIVE
  Intractable incontinence affects a large number of children and young adults in the US. The goal of this study is to evaluate the long-term outcomes of surgical access for administration of antegrade continence enemas (ACE) in affected children and young adults.
  
  
  METHODS
  Patients who underwent surgical procedure to enable administration of ACE from 1994 to 2011 were retrospectively reviewed. Data collected included patient demographics, primary diagnosis, surgical technique, conduit used, complications, follow-up duration, and social continence.
  
  
  RESULTS
  Sixty eighty patients underwent surgery to enable ACE; mean follow up was 61 months. Enteral conduit (EC) was performed in 19 patients, tube cecostomy catheters (CC) in 49. Meningomyelocele was diagnosed in 60% of patients. Mean age was 11 (1.67-53) years. Complications included tube dislodgement (43%), granulation tissue (46%), site infection (13%), leakage (32%), break in the tube (6%) and tract stenosis (6%). Complete social continence was achieved in 68%, partial continence was achieved in 29%, and no benefit was achieved in 3% of patients. The rate of complications and incontinence resolution following CC was 78% and 66%, and following EC 89% and 74%. The differences were not statistically significant. CC patients developed granulation tissue more frequently (53%) and leaks of fecal material less frequently (20%) compared to EC patients (26% and 53%) (p < 0.05 and < 0.01). Although children 7 years or younger developed more overall complications (94%) than older patients (69%; p < 0.05), there was not a significant difference in the frequency of any one complication or in the rate of continence, between the two groups. Multivariate analysis showed that EC is three times more likely to be complicated by fecal leakage. CC patients are at greater risk to develop granulation tissue (p < 0.05).
  
  
  CONCLUSIONS
  Most patients achieved social continence and improved hygiene with the aid of ACE. Younger children also benefited greatly from institution of ACE. CC was associated with fewer major complications such as leak of fecal contents than EC but required regular tube changes.
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.
authors.forename: Maen M
authors.initials: MM
authors.lastname: Masadeh
authors.forename: Michael
authors.initials: M
authors.lastname: Krein
authors.forename: Joshua
authors.initials: J
authors.lastname: Peterson
authors.forename: Molly
authors.initials: M
authors.lastname: Bauer
authors.forename: Laura
authors.initials: L
authors.lastname: Phearman
authors.forename: Graeme
authors.initials: G
authors.lastname: Pitcher
authors.forename: Junlin
authors.initials: J
authors.lastname: Liao
authors.forename: Joel
authors.initials: J
authors.lastname: Shilyansky
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002431:Cecostomy; D002648:Child; D002675:Child, Preschool; D004733:Enema / Q000379:methods*; D004766:Enterostomy / Q000379:methods*; D005242:Fecal Incontinence / Q000601:surgery / Q000628:therapy*; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: Anorectal malformation; Antegrade continent enema; Cecostomy; Incontinence; Meningomyelocele